http://www.sundayherald.com/53306
Blood transfusion errors surge
Two deaths linked to mistakes after 439 incidents of patients getting the wrong type
By Judith Duffy
THE number of patients given the wrong blood in botched hospital transfusions rose by more than a quarter last year. Although in most cases the patients were not harmed, two deaths were linked to receiving an incorrect blood component.
An annual report on the safety of transfusions has revealed that in 2004 there were 439 reports of errors, including patients receiving either the wrong type of blood or blood intended for another person.
The figures were revealed in the Serious Hazards of Transfusion (Shot) report – a voluntary reporting scheme run by a group of NHS clinicians. Hilary Jones, Shot manager, said more investment was needed in training and education for staff to stop preventable mistakes occurring. “The most common errors we come across are those based at the patient’s bedside, where the final patient check isn’t carried out adequately,” said Jones. “If you look at near-miss incidents, where the error was picked up before a transfusion took place, it changes to more errors being made at the stage when samples are taken from a patient.
“Error actually occurs as the sample is taken, so either it is taken from the wrong patient or it’s taken from the right patient but labelled as somebody else’s. We keep harping on about education and ongoing training, and I think probably the biggest issue is that there just aren’t the resources out there.”
The number of “wrong blood” incidents has risen steadily since the introduction of Shot. Figures show that in 1996-7, 63 cases were recorded. But Jones said this was likely to be due to greater awareness of the reporting system. “Each year there has been an increase. That is almost entirely due to people becoming more aware and more willing to report, rather than an increase in incidents,” she said.
In one high-profile case, a 77-year-old man died after being given the wrong blood during an operation because staff confused him with another patient with the same name. The error was spotted half-way through the surgery but Graham Davies, from South Wales, died soon afterwards.
With more than three million blood components issued by the UK transfusion services every year, health experts point out that the number of errors is comparatively low. Dr Sam Rawlinson, a clinical director of the Scottish National Blood Transfusion Service, said the risk of a mistake occurring was “extremely small”. “When we look at transfusion, we have put enormous effort into making the risk as small as possible,” he said. “Not only in terms of trying to make the blood as safe as possible but also in terms of actively encouraging transfusion to be given when appropriate.
“When you look at it overall, the level of safety is huge, but obviously it can never be risk-free.”
Rawlinson said a new “user-friendly” system was being introduced in Scottish hospitals – currently the responsibility of Health Minister Andy Kerr – to help minimise mistakes and comply with new EU legislation. “This is a simple blood labelling system that will enable all the hospitals to have a common system which enables us to have common training,” he said.
“Every hospital developed its own system based on the same guidelines. What we are doing is trying to move to a system which is the same. It is not universal, but it is being developed, piloted, proven to work and is being adopted by a lot of hospitals.
“The idea is to have a simple system with people who are well trained and have, as much as possible, a unified Scottish approach.”
11 December 2005
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